Provider Demographics
NPI:1285045674
Name:PETERSON, AMBER RAE (LPN)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:RAE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7404 TIMBERLINE CT
Mailing Address - Street 2:
Mailing Address - City:BLACK HAWK
Mailing Address - State:SD
Mailing Address - Zip Code:57718-9545
Mailing Address - Country:US
Mailing Address - Phone:605-593-2682
Mailing Address - Fax:
Practice Address - Street 1:7404 TIMBERLINE CT
Practice Address - Street 2:
Practice Address - City:BLACK HAWK
Practice Address - State:SD
Practice Address - Zip Code:57718-9545
Practice Address - Country:US
Practice Address - Phone:605-593-2682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDP011318164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse